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Ultrasound Corner |

A 21-Year-Old Man With “Sloshing” in the Chest FREE TO VIEW

Shoeb Ahsan, MD; Drew Thompson, MD; Rob Arntfield, MD
Author and Funding Information

CORRESPONDENCE TO: Shoeb Ahsan, MD, Department of Medicine, Western University, 800 Commissioners Rd E, London, ON, N6A 5W9, Canada


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(6):e169-e171. doi:10.1016/j.chest.2016.01.035
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Published online

A 21-year-old man presented to the ED with a 2-month history of chest pain. During the preceding several days, he described hearing “sloshes” in his chest with positional changes, which ultimately prompted his visit. He has a history of epilepsy and was compliant with his phenytoin therapy.

Further questioning suggested a history of a possible fall 2 months prior, while intoxicated. Subsequent to this event, he had been having intermittent pain in his chest. He denied fevers, night sweats, chills, cough, or shortness of breath. He denied ever having similar symptoms in the past. The pain was not worse on exertion nor positional. He is unemployed and uses marijuana occasionally. He denied any other drug use.

On examination, he was afebrile with temperature of 37.1°C, blood pressure was 131/67 mm Hg, heart rate was 116 beats/min, respiratory rate was 15 breaths/min, and he had an oxygen saturation of 98% on room air. He did not appear in any distress and had no murmurs, rubs, or gallops. On auscultation, he had normal breath sounds in the right lung field, whereas the left chest revealed bronchial breath sounds in the apical field with absent sounds in the remainder of thorax.

Laboratory investigations revealed a WBC of 17.1, hemoglobin of 11 g/dL, and platelet count of 605. International normalized ratio was 1.4. Chest radiography demonstrated complete opacification of the left hemithorax with an air-fluid level in the superior chest, a midline shift to the right, and no identified rib fractures (Fig 1).

Figure Jump LinkFigure 1 Patients initial posteroanterior chest film on initial presentation. The left hemithorax displays air-fluid level.Grahic Jump Location

Thoracic ultrasonography (US) was undertaken to further clarify the nature of this opacification (Video 1).

Question: Based on the ultrasound findings, what is the nature of the opacification seen on chest radiograph?

Answer: We identified an effusion within the pleural space that was isoechoic without loculations or septae and identified hyperechoic reflections within the effusion and loss of lung sliding. These constellation of findings were concerning for a pyopneumothorax.

The patient in our study presented with nonspecific signs and symptoms on clinical evaluation, with a whiteout and air fluid level in the left hemithorax identified on chest radiograph. His history, physical examination, and chest radiograph, though concerning, did not sufficiently inform providers as to the underlying diagnosis for this young man with vague, subacute historical details.

Thoracic US offers several advantages over basic chest films. Evaluation of the thorax can be performed in real-time, evaluating structures dynamically. It can locate abnormalities and define them within the pleural space, lung parenchyma or chest wall. Thoracic US also offers greater sensitivity in detecting pleural disease than chest radiographs. Furthermore, it can clarify a radiographic opacification as an effusion, consolidation, atelectasis or a mass. It can characterize an effusion with loculation or septae, identify pneumothoraces with greater precision than radiographs, and simultaneously assess for additional abnormalities of the underlying lung parenchyma.,

One possible diagnosis is a simple pleural effusion. When identified, transudative pleural fluid is likely anechoic and may have associated compressive atelectasis (Video 2). This is in stark contrast to normal US findings at the posterior axillary line, in which normal aerated lung produces the curtain sign with no discernible anechoic areas in the far field. Alternatively, pleural fluid may be isoechoic or hyperechoic containing inflammatory debris, septae, or areas of loculation. Either of these findings is diagnostic of an exudative effusion representing blood, empyema, or inflammatory debris (Video 2). In the patient in our study, we identified areas within the pleural space that appeared isoechoic without loculations or septae (Videos 1, 2).

In addition, we also identified loss of lung sliding. This finding can be concerning for pneumothorax, but many disease processes can have similar findings. To rule in the diagnosis of pneumothorax, loss of lung sliding and presence of a lung point approximates 100% sensitivity in critical care settings (Video 2). In the patient in our study, this finding may be explained primarily from the presence of a complex pleural effusion.

Furthermore, we found hyperechoic reflections within the effusion (Videos 1, 2). This may represent air particles at fluid-air interface signifying trapped air or gas within the pleural space. The combination of a complex effusion with trapped air and pneumothorax lead to a diagnosis of either pyo- or hemopneumothorax.

There are several characteristics on thoracic US that assist in making the diagnosis of hydro-, hemo-, or pyopneumothorax. Hyperechoic reflections representing an air-fluid interface, movement of pleural fluid with respiration, and loss of lung sliding are all signs on US on both empyemic and nonempyemic hydropneumothorax.,

Pyopneumothorax in particular can be difficult to differentiate from lung abscess. CT scan is often the diagnostic modality of choice in differentiating these two entities. US can reliably differentiate both as well as CT., Lung abscesses are more likely to have irregular or jagged borders and distinct separation of pleural spaces with regions of varying echogenicity when compared with pyopneumothoraces (Video 2).

However, one of the best signs of differentiating between these two diagnoses is suspended microbubbles. In one case series of pyopneumothoraces studied with thoracic US, microbubbles were present in 18/19 cases and in no cases of lung abscesses. These appear as hyperechoic echoes that scatter from the source representing air that is suspended in free-flowing fluid as seen in the patient in our study. US energy propagates through the fluid density medium and, when in contact with free air, its reflections are detected by the US probe as hyperechoic densities or back scatter. These were found in the patient in our study.

Next steps: Thoracic surgery was consulted with subsequent thoracentesis and chest tube placement in the left pleural space. Copious foul green drainage with air bubbles was suctioned from the pleural space. The patient was subsequently treated with IV antibiotics and improved clinically.

The initial aspiration and evacuated contents of the thoracentesis are shown (Fig 2). Streptococcus anginosus was identified on fluid culture, an organism typically part of normal oral and gastrointestinal flora. US findings of loss of lung sliding and echogenic fluid with microbubbles within pleural space in addition to this fluid culture confirmed the diagnosis of a pyopneumothorax.

Figure 2
Figure Jump LinkFigure 2 (A) Initial aspiration contents shown. (B) Drainage contents after suction from chest tube.Grahic Jump Location

We hypothesized that the likely sequence of events was an aspiration event during a seizure with subsequent aspiration pneumonia. This in turn, led to a parapneumonic effusion turned empyema with a gas-forming organism.

In conclusion, thoracic US can quickly characterize and diagnose pleural or lung pathology that may remain undifferentiated on plain radiographs, often without the need for CT. This modality therefore alters management and disposition, and reduces radiation exposure and allows for more timely diagnoses to be made.

  • 1.

    US can detect septae, hyperechoic inflammatory debris, blood, or loculation in diagnosing a complicated pleural effusion.

  • 2.

    US can be reliably used to differentiate lung abscess from pyo-pneumothoraces.

  • 3.

    Suspended microbubbles is specific sign on US for hemo- or pyopneumothorax.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: R. T. A. is a consultant for Sonosite. None declared (S. A., A. C. T.).

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Yu C.J. .et al Ultrasound study in unilateral hemithorax opacification. Image comparison with computed tomography. Am Rev Respir Dis. 1993;147:430- [PubMed]journal. [CrossRef] [PubMed]
 
King S. .Thomson A. . Radiologic perspectives in empyema. Br Med Bull. 2002;61:203-214 [PubMed]journal. [CrossRef] [PubMed]
 
Yang P.C. .et al Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol. 1992;159:29-33 [PubMed]journal. [CrossRef] [PubMed]
 
Lichenstein D. . Lung ultrasound in the critically ill. Curr Opin Crit Care. 2014;20:315-322 [PubMed]journal. [CrossRef] [PubMed]
 
Lin F.C. .et al Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography. Am J Med Sci. 2004;327:330-335 [PubMed]journal. [CrossRef] [PubMed]
 
Wu H.D. .et al Differentiation of lung abscess and empyema by ultrasonography. J Formos Med Assoc. 1991;90:749-754 [PubMed]journal. [PubMed]
 
Williford M.E. .Godwin J.D. . Computed tomography of lung abscess and empyema. Radiol Clin North Am. 1983;21:575-583 [PubMed]journal. [PubMed]
 
Ruoff K.L. . Streptococcus anginosus (“Streptococcus milleri”): the unrecognized pathogen. Clin Microbiol Rev. 1988;1:102- [PubMed]journal. [PubMed]
 
Kobashi Y. .et al Clinical analysis of cases of empyema due to Streptococcus milleri group. J Infect Dis. 2008;61:484- [PubMed]journal
 

Figures

Figure Jump LinkFigure 1 Patients initial posteroanterior chest film on initial presentation. The left hemithorax displays air-fluid level.Grahic Jump Location
Figure Jump LinkFigure 2 (A) Initial aspiration contents shown. (B) Drainage contents after suction from chest tube.Grahic Jump Location

Tables

References

Yu C.J. .et al Ultrasound study in unilateral hemithorax opacification. Image comparison with computed tomography. Am Rev Respir Dis. 1993;147:430- [PubMed]journal. [CrossRef] [PubMed]
 
King S. .Thomson A. . Radiologic perspectives in empyema. Br Med Bull. 2002;61:203-214 [PubMed]journal. [CrossRef] [PubMed]
 
Yang P.C. .et al Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol. 1992;159:29-33 [PubMed]journal. [CrossRef] [PubMed]
 
Lichenstein D. . Lung ultrasound in the critically ill. Curr Opin Crit Care. 2014;20:315-322 [PubMed]journal. [CrossRef] [PubMed]
 
Lin F.C. .et al Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography. Am J Med Sci. 2004;327:330-335 [PubMed]journal. [CrossRef] [PubMed]
 
Wu H.D. .et al Differentiation of lung abscess and empyema by ultrasonography. J Formos Med Assoc. 1991;90:749-754 [PubMed]journal. [PubMed]
 
Williford M.E. .Godwin J.D. . Computed tomography of lung abscess and empyema. Radiol Clin North Am. 1983;21:575-583 [PubMed]journal. [PubMed]
 
Ruoff K.L. . Streptococcus anginosus (“Streptococcus milleri”): the unrecognized pathogen. Clin Microbiol Rev. 1988;1:102- [PubMed]journal. [PubMed]
 
Kobashi Y. .et al Clinical analysis of cases of empyema due to Streptococcus milleri group. J Infect Dis. 2008;61:484- [PubMed]journal
 
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